How to Submit a Superbill to Ambetter for Therapy Reimbursement

Ambetter Out-of-Network Process

Ambetter, offered through the Centene Corporation, provides Marketplace health plans with limited OON coverage. Most Ambetter plans are HMO-based and do not cover OON services except for emergencies. Members on EPO or PPO plans may have some OON mental health benefits and can submit superbills via the Ambetter member portal at ambetterhealth.com or by contacting member services for a paper claim form.

Common Denial Reasons

• ✗Member has an HMO plan with no OON benefits for non-emergency care
• ✗Provider is not licensed in the state where the member's plan is issued
• ✗Prior authorization was not obtained for outpatient mental health services
• ✗Claim submitted after the 90-day timely filing window

Tips for Getting Reimbursed by Ambetter

• ✓Verify plan type before starting treatment — Ambetter HMO clients will have no OON coverage and will owe the full fee
• ✓Ambetter EPO and PPO plans exist in some states and do carry OON mental health benefits
• ✓Advise clients to call the member services number on their Ambetter card to request an OON benefits explanation in writing
• ✓Prior authorization is often required for more than 6 sessions — check with Ambetter before each authorization period